Academic Title Application Form
Please attach your curriculum vitae when submitting this application form.
APPLICANT DETAILS
Surname:
Given Names:
Preferred Contact Telephone No:
Current Title:
Date of Birth:
Preferred Contact Email:
Postal Address:
Work Address:
Current Job Title:
Current Employment Location: (e.g., Gold Coast Hospital)
Please provide details of your medical registration, including registration number and type of registration, or
other registration under APHRA or appropriate registration agency applicable.
Registration No: __________________________
Registration Type:_________________________
Registration Expiry date: _____/_____/_________
Specialty: (e.g., Emergency Medicine)
Academic Title Applied For (tick one):
Clinical Teacher
Lecturer / Research Fellow
Associate Professor / Principal Research Fellow
Associate Lecturer
Senior Lecturer / Senior Research Fellow
Professor
Do you believe you are eligible to receive a guaranteed* Academic Title? (tick one)
Yes
No
*Medical Interns, House Officers/ Registrars, General Practitioners, Medical Specialists and other registered health practitioners who:
 are employed in healthcare organisations that are recognised as participating Griffith University teaching organisations, and
 wish to contribute to teaching and/or research at the University,
 will be guaranteed an offer of the following academic titles upon receipt by the University of a completed Academic Title Application
Form.
o
Medical Interns undertaking their post-graduate year 1 (PGY1) will be offered the title of Associate Lecturer for the duration
of their Medical Internship appointment; and
o
House Officers/ Registrars or equivalent who have completed PGY1 will be offered the title of Lecturer; and
o
Other Registered Health Practitioners (for example a registered Nurse or Physiotherapist) will be offered the title of Lecturer;
and
o
General Practitioners who are either a member of the Royal Australian College of General Practitioners or have significant
professional experience in general practice, and Medical Specialists will be offered the title of Senior Lecturer; and
o
Other Registered Health Practitioners who hold a postgraduate clinical qualification (for example a post-entry level or
specialist clinical degree) or a full fellowship with a recognized Australian health professional body will be offered the title of
Senior Lecturer.
Intended Host School / Research Centre (tick one)
Griffith Health
School of Dentistry and Oral Health
School of Human Services and Social Work
School of Medical Science
School of Medicine
School of Nursing and Midwifery
Griffith Sciences
School of Natural Sciences
Eskitis Institute for Cell and Molecular Therapies
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Academic Title Application Form
School of Pharmacy
School of Allied Health Sciences
School of Applied Psychology
Griffith Health Institute
Australian Institute for Suicide Research
and Prevention
Institute for Glycomics
Current involvement with Griffith University
Please outline your current involvement with the University and who you have discussed your application with prior to
submission.
Note: This is a mandatory field for completion and will assist the Committee in their assessment of your
application.
Proposed involvement with Griffith as an Academic Titleholder.
Please briefly outline your proposed involvement with the University if you are successful in being awarded an academic
title. Note: Eligibility Criteria for Academic Titleholders can be found at Appendix A of the Griffith University Academic
Titles Policy.
Note: This is a mandatory field for completion and will assist the Committee in their assessment of your
application.
Referees
Please provide details for three (3) referees, include their name, title, address, phone number, fax number, and email
address.
Note: Referees will be provided with a copy of the applicants CV and application as required.
Note: Applications for Associate Professor require one referee of national standing and one of international standing.
Applications for Professor require two referees of international standing.
Referee 1:
Referee 2:
Referee 3:
Intellectual Property
☐
I agree to abide by the conditions of the University’s Intellectual Property Policy as published on the
University’s website (please tick)
OTHER INFORMATION:
Please feel free to include any other information that you believe may support your application.
Note:
only enter additional information that does not appear in your CV
applicants who are seeking the title of Clinical Lecturer or who believe they are eligible to receive a
Guaranteed Academic Title (see over page) need not feel obliged to provide Other Information in this section
if they do not wish to.
Qualifications and Associations:
Research Interests / Contributions:
Significant Publications / Grants:
Teaching Experience:
Academic Supervision of Research Students:
Clinical Service:
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Academic Title Application Form
REQUIRED ATTACHMENTS:
☐ Please attach your Curriculum Vitae (CV). If you require a CV template to follow, please visit the
University’s CV Template link.
☐ Please provide details of your medical malpractice insurance and attach evidence of the insurance
details.
☐ If you are a Qld Health employee, please indicate in the tick box as you will be indemnified by Qld
Health.
SUBMISSION OF APPLICATIONS
Applications can be submitted using the online application form (www.griffith.edu.au/health/academictitles)
or by emailing or mailing a completed application for academic title form together with a CV to:
The Secretary
Academic Titles Committee
Office of Human Resource Management
Gold Coast Campus
Building G34 1.19, Chancellery Building
Griffith University QLD 4222
Email: academictitles@griffith.edu.au
Form updated 22.05.2015
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Academic Title Application Form